Table 2.
Summary of key surgical recommendations in different guidelines for acute pancreatitis management
|
IAP1 (grade A and B)[31]
|
WSES2 (grade 1A, 1B, or 1C)[4]
|
AGA (pancreatic necrosis)[33] |
| Mild AP is not an indication for pancreatic surgery (grade B recommendation) | Routine ERCP is not indicated (1A) | Drainage and/or debridement of pancreatic necrosis is indicated in patients with IPN |
| IPN in patients with clinical signs and symptoms of sepsis is an indication for intervention (recommendation grade B) | ERCP is indicated in patients with GSAP and cholangitis (1B) | Pancreatic debridement should be avoided in the early, acute period (first two weeks) |
| Early surgery is not recommended within 14 d after the onset of the disease in patients with necrotic pancreatitis (recommendation grade B) | Clinical deterioration with signs of INP is an indication of intervention (1C) | Percutaneous and transmural ED are both appropriate first-line nonsurgical approaches to the management of patients with WON |
| Interventional management should favor an organ-preserving approach (grade B recommendation) | As a continuum in a step-up approach after percutaneous/endoscopic procedure (1C) | Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early acute period (< 2 wk) |
| ES is an alternative to cholecystectomy in those who are not fit to undergo surgery (grade B recommendation) | In IPN, percutaneous drainage as the first-line of treatment (1A) | SEMS in the form of LAMS appears superior to plastic stents for endoscopic transmural drainage of necrosis |
| Minimally invasive surgical strategies result in fewer postoperative new-onset OF (1B) | The use of DEN should be reserved for those patients with limited necrosis and not responding to endoscopic transmural drainage | |
| Laparoscopic cholecystectomy is recommended during index admission in mild GSAP (1A) | Minimally invasive operative approaches to the debridement of IPN are preferred to open approaches | |
| The risk of recurrent pancreatitis is reduced when ERCP and sphincterotomy are performed during index admission (1B) | ||
| Over-resuscitation of patients with early SAP should be avoided; intra-abdominal pressure monitoring is necessary (1C) | A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage, followed by DEN, and then surgical debridement is reasonable | |
| OA should be avoided if other strategies can be used to manage IAH (1C) | ||
| Not to use OA after necrosectomy (1C) | ||
| Not to debride or perform an early necrosectomy if forced to perform an early OA due to ACS (1A) | ||
| For patients with disconnected left pancreatic remnants after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy can be performed |
Grade A: Strong evidence that requires a meta-analysis of randomized controlled trials or at least one randomized controlled trial (evidence categories Ia and Ib); Grade B: Intermediate evidence, requires nonrandomized clinical studies (evidence categories IIa, IIb, and III).
Grading of recommendations assessment 1A: Strong recommendation, high-quality evidence; 1B: Strong recommendation, moderate-quality evidence; 1C: Strong recommendation, low-quality or very low-quality evidence.
ACS: Abdominal compartment syndrome; AP: Acute pancreatitis; DEN: Direct endoscopic necrosectomy; ES: Endoscopic sphincterotomy; LAMS: Lumen-apposing metal stents; OA: Open abdomen; SAP: Severe acute pancreatitis; SEMS: Self-expanding metal stents; VARD: Video-assisted retroperitoneal debridement; WON: Walled-off necrosis; ERCP: Endoscopic retrograde cholangiopancreatography; IPN: Infected pancreatic necrosis; IAP: International Association of Pancreatology; WSES: World Society of Emergency Surgery; AGA: American Gastroenterological Association; GSAP: Gallstone-associated acute pancreatitis; INP: Infected necrotizing pancreatitis; ED: Endoscopic drainage.